EMERGENCY FORM
INSTRUCTIONS TO PARENTS/GUARDIANS:
(1) Complete all items on this side of the form. Sign and date where indicated.
(2) If your child has a medical condition which might require emergency medical care, complete the back side of the form. If necessary, have your child’s health practitioner review that information.
NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY.
Child’s Name ______Birth Date ______
Enrollment Date ______Hours & Days of Expected Attendance ______
Child’s Complete Home Address ______
Mother/Guardian’s Name ______
Home Telephone ______
Employer/School ______
Complete Home Address (If different from above) ______
Work Telephone ______Cellular Phone ______
Father/Guardian’s Name ______
Home Telephone ______
Employer/School ______
Complete Home Address (If different from above) ______
Work Telephone ______Cellular Phone ______
Name of Person Authorized to Pick-up Child (daily)______
Last First Relationship to Child
Address ______
Street/Apt# City State Zip Code
When parents/guardians cannot be reached, list at least one person who may be contacted to pick up the child in an emergency:
1. Name ______Telephone (H) ______(W) ______
CompleteAddress______
2. Name ______Telephone (H) ______(W) ______
Complete Address______
(Initials/Date) (Initials/Date) (Initials/Date) (Initials/Date)
OCC 1214 (Revised 7/15) - Page 1 of 2 - All previous editions are obsolete
NSTRUCTIONS TO PARENT/GUARDIAN:
IN EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes the responsible person at the child care facility to have your child transported to that hospital.
Signature of Parent/Guardian ______Date ______
ANNUAL UPDATES ______
Child’s Physician or Source of Health Care ______Telephone ______
Complete Address______
1) Complete the following items, as appropriate, if your child has a condition(s) which might require emergency medical care.
(2) If necessary, have your child’s health practitioner review the information you provide below and sign and date where indicated.
Child’s Name: ______Date of Birth: ______
Medical Condition(s): ______
______
Medications currently being taken by your child: ______
______
Date of your child’s last tetanus shot: ______
Allergies/Reactions: ______
______
EMERGENCY MEDICAL INSTRUCTIONS:
(1) Signs/symptoms to look for: ______
______
(2) If _ signs/symptoms appear, do this: ______
(3) To prevent incidents: ______
______
______
OTHER SPECIAL MEDICAL PROCEDURES THAT MAY BE NEEDED: ______
______
______
______
COMMENTS: ______
______
______
______
______
Note to Health Practitioner:
If you have reviewed the above information, please complete the following:
______
Name of Health Practitioner Date
______(_____)______
Signature of Health Practitioner Telephone Number
OCC 1214 (Revised 7/15) - Page 2 of 2 - All previous editions are obsolete.